Rocking Horse Community Health Center
POLICIES AND PROCEDURES
Policy # and Title:
1601–Quality Control Testing For CLIA Waived Tests
Prepared by:Lisa Saunders, RN
Approved by: Board of Directors
Effective date:May 30, 2006 / Applicable to:All Rocking Horse Sites
Number of pages:1

Policy:

All CLIA waived tests will be monitored for quality control. All employees performing CLIA waived testing will be evaluated for competency

Procedure:

  1. The procedures and frequency for monitoring quality control will follow the manufacturer’s recommendation.
  2. The manufacturer’s instructions will be kept in the testing log binder.
  3. All employees who are trained and will perform testing will have access to this binder at all times. Designated staff will be responsible for ensuring all logs and testing are up to date and controls are current.
  4. As per manufacturer’s recommendations external control testing will be performed on each new lot number. With each new lot number, a new patient test log will be created. This test log will document at a minimum patient name, date of birth (2 identifiers), test result, internal control completion, and initials of person completing the test.
  5. Separate logs will be kept in the testing binder behind the tab for each test section to document external quality control results.
  • Only staff with adequate training and confirmation of skills will perform laboratory tests and all staff performing such tests will adhere to all manufacturers’ recommendations for performance.
  • All training for staff will be documented in new employee orientation and at annual competence and confirmed by the Clinical Team Manager.
  • Annual competency evaluation will include job specific skills checklist and written and observational testing.
  • New employees will be trained on all current test procedures prior to performing any test. All staff will be oriented and trained on any new testing procedure prior to performing any new test.
  • Documentation of skills assessment will be kept in each employee’s personnel file.

Original Date: 5/30/2006Approved Date: 5/30/2006

Reviewed/Revised Date: 10/08/2009Approved Date:

Reviewed/Revised Date: 9/08/2010Approved Date: 12/09/2010

Reviewed/Revised Date: 9/13/2011Approved Date:

Reviewed/Revised Date: 10/11/2012Approved Date:

Reviewed/Revised Date: 10/01/2013Approved Date:

Reviewed/Revised Date: 09/02/2014Approved Date:

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